Procedure

It is difficult to perform fibreoptic bronchoscopy in a nasally intubated patient. A narrow-lumen scope can be used but suction is limited.

1. Pre-oxygenate with FI02 1.0. Monitor with pulse oximetry.

2. Increase pressure alarm limit on ventilator.

3. Lubricate scope with lubricant gel/saline.

4. If unintubated, apply lidocaine gel to nares ± spray to pharynx.

5. Consider short-term IV sedation ± paralysis.

6. Insert scope nasally (in a non-intubated patient) or through catheter mount port in an intubated patient. An assistant should support the endotracheal tube during the procedure to minimise trauma to both trachea and scope.

7. Inject 2% lidocaine into trachea to prevent coughing and haemodynamic effects from tracheal/carinal stimulation.

8. Perform thorough inspection and any necessary procedures. If Sp02 <85% or haemodynamic disturbance occurs, remove scope and allow re-oxygenation before continuing.

9. Bronchoalveolar lavage is performed by instillation of at least 60ml of (preferably warm) isotonic saline into affected lung area without suction, followed by aspiration into a sterile catheter trap. All bronchoscopic samples should be sent promptly to the lab.

10. Reduction of effective endotracheal tube lumen and suction may affect the tidal volume, leading to hypoxaemia and/or hypercapnia.

11. After procedure, reset ventilator as appropriate.

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